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Perioperative Management Flashcards

(102 cards)

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1
Q

Why is smoking history important pre-op?

A

When was their last cigarette? It constricts the airways and makes them hyper-reactive so they may go into bronchospasm more easily
Also heavy smokers may not know they have COPD so take care giving O2 to wake them up

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2
Q

What are the main aspects of physical examination pre-op?

A

Airway assessment
CVS
Respiratory

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3
Q

What is ASA grade 1?

A

Normal healthy patient

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4
Q

What is ASA grade II?

A

Patient with mild systemic disease and no functional limitations

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5
Q

What is ASA grade III?

A

Moderate to severe disease that results in some functional limitations

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6
Q

What is ASA Grade IV?

A

Severe systemic disease that is a constant threat to life and functionally incapactitating

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7
Q

What is ASA grade V?

A

Moribund patient not expected to survive 24 hours with or without the surgery

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8
Q

What does E after ASA grade mean?

A

That the procedure is an emergency

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9
Q

What investigations are performed routinely at pre-assessment?

A 
Urinalysis
ECG if >50y
FBC
Blood glucose in diabetics
Pregnancy test for all females of reproductive age
U&Es if >60y
Coagulation, group&save
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10
Q

What are the time limits in NBM?

A

Clear fluids up to 2 hours before procedure

Light meal 6 hours before

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11
Q

What does -plasty mean at the end of a surgical procedure?

A

Surgical refashioning to regain good function

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12
Q

What does -stomy mean?

A

Artificial Union between a conduit and another conduit/the outside world

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13
Q

What is a cyst?

A

Fluid-filled cavity lined by epi/endothelium

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14
Q

What is colic?

A

Intermittent pain from over-contraction or obstruction of a hollow viscus

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15
Q

What is a sinus?

A

Blind-ending tract

Typically lined by epithelial or granulation tissue, which opens to an epithelial surface

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16
Q

What is an ulcer?

A

Interruption in the continuity of an epi/endothelial surface

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17
Q

What are the aims of preoperative assessment?

A

Know planned procedure
Improve any comorbidities which may increase risk of an adverse outcome
Anticipate potential problems
Informed consent
Appropriate prophylactic measures and premedication
Trusting patient-doctor relationship

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18
Q

What surgical presentations can warfarin cause?

A

Rectus sheath haematoma
Intraperitoneal bleeding
Retroperitoneal haematoma

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19
Q

What are the main causes of acute pancreatitis?

A

Gallstones

Alcohol

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20
Q

What drugs can cause diarrhoea?

A 
Beta blockers
ACE inhibitors
Statins
Antibiotics
Metformin
Iron
Laxatives
Mefenamic acid
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21
Q

What drugs can cause constipation?

A 
Antimuscarinics
Opiates
Iron
Laxatives (chronic)
Aluminium-containing antacids
Mebeverine
Gaviscon
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22
Q

How long before surgery should clopidogrel be stopped?

A

7 days before

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23
Q

How long before surgery should aspirin be stopped?

A

DO NOT STOP

Cardio and cerebroprotective benefits outweigh slight increased bleeding risk

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24
Q

How should statins be managed perioperatively?

A

Don’t stop

Reduce periop mortality

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25
How should beta blockers be manage perioperatively?
Don't stop | Risk of rebound angina/infarction when stopped suddenly
26
How should oral hypoglycaemics be managed perioperatively?
Stop from day of surgery
27
How should the OCP be managed perioperatively?
Stop at least 4 weeks before surgery (give alternative contraceptive advice) Restart 2 weeks after surgery
28
How should HRT be managed periop?
Stop at least 4 weeks before surgery | Restart 2 weeks post-op
29
How should steroid be managed periop?
DO NOT STOP | Can lead to Addisonian crisis
30
When should warfarin be stopped before surgery?
AF: 5 days Prosthetic heart valve: 5 days, keep INR 2-3 using heparin Previous DVT/PE: 5 days, high-dose prophylactic LMWH
31
How do you immediately reverse warfarin?
Beriplex - synthetic factors 2, 7, 9 and 10
32
How else can you reverse warfarin?
IV vitamin K (1-5 mg slowly) | Takes 3hrs
33
How can you check for postoperative ileus?
Ask the patient if they have passed wind | If yes, then the colon is working and hence everything else is too
34
Which patients should have prophylactic LMWH?
All patients over 20 having abdominal surgery | Patients having neck surgery should not
35
What dose of dalteparin is used for VTE prophylaxis?
2,500 or 5,000 for high-risk patients
36
What antibiotics are used for prophylaxis of wound infection?
Ceftriaxone + metronidazole | Or augmentin
37
What is the treatment for opiate OD?
Naloxone 0.4mg IV
38
What are the steps involved in reversing anaesthetic?
Wellbeing (pain and PONV) then C B A... CVS stable Breathing for themselves Airway (&O2)
39
Name a muscle relaxant commonly used in anaesthesia
Atracurium
40
Why might atropine be given in laparoscopic surgery?
Vagal nerve stimulation can cause bradycardia
41
Why is increased pressure needed to ventilate patients during laparoscopic surgery?
Abdomen is inflated, making it harder for the diaphragm to move down
42
How are CO2 levels managed during surgery?
If pCO2 rises during op, increase rate of ventilation | High pCO2 at the end is good as it stimulates the patient to start self-ventilating
43
What are the potential respiratory complications post-op?
Hypo ventilation | Hypoxia
44
What can cause hypo ventilation postop?
Upper airway obstruction - decreased muscle tone, secretions, sleep apnoea Laryngeal obstruction Opioids causing respiratory depression
45
What can cause hypoxia postop?
Hypo ventilation Ventilation perfusion mismatch eg PE Pain Using too much O2 eg shivering
46
Why should patients only be delivered to the ward once they have a normal temperature?
Shivering increases O2 demand Hypothermia reduces enzyme activity in clotting Heat needed for wound healing
47
What can cause postop hypotension?
Drugs Epidurals Volume loss
48
What is the main cause of postop hypertension?
Pain
49
What are the risk factors for PONV?
``` Motion sickness Gynae surgery Previous PONV Child Female Anxiety ```
50
What are the anaesthetic causes of PONV?
Opioids Gases Pain Not enough fluid
51
What are the 5 parameters measured in EWS?
``` Heart rate Resp rate Temperature BP CNS (AVPU) ```
52
What is the most important parameter in EWS?
Resp rate. Indicates hypoxia, hypercapnia and metabolic acidosis (DKA, sepsis, lactic acidosis)
53
How should you give oxygen to a COPD patient?
Venturi mask
54
What concentration of oxygen do nasal cannulae deliver?
24-35%
55
Define pain
An unpleasant emotional and sensory experience resulting from a stimulus causing, or likely to cause, tissue damage
56
What are the effects of pain?
Tachycardia, hypotension Inability to deep breathe or cough Nausea and poor appetite Poor mobility Stress response - sodium and water retention, oedema Poor sleep, depression, illness behaviour, inability to work
57
What is the pain pathway?
``` Stimulus Dorsal horn of spinal cord Modulation in Rexed laminae Ascending pathways Modulation by brain Descending pathways Effector site reflexes ```
58
What does neuropathic pain feel like?
Burning
59
What is step 1 in the WHO pain ladder?
Non-opioids eg aspirin, NSAIDs or paracetamol
60
What is step 2 on the WHO pain ladder?
Mild opioids eg codeine, with or without non-opioids
61
What is step 3 on the WHO pain ladder?
Strong opioids eg morphine, with or without non-opioids
62
How does paracetamol work?
Inhibits CNS prostaglandin synthesis and blocks bradykinin-sensitive chemoreceptors peripherally
63
What is the adult dose of paracetamol?
1g every 4-6hrs
64
How do NSAIDs work?
COX inhibition to reduce synthesis of peripherally-acting inflammatory mediators of pain
65
What does COX-1 do?
Constitutive production of inflammatory mediators eg GI, renal
66
What are the side effects of NSAIDs?
GI: peptic ulcers, erosions and GI haemorrhage Renal: can reduce renal blood flow Resp: bronchospasm Bleeding: anti-platelet effect Cardiac: fluid retention and cardiac failure in borderline patients
67
What is the relationship between codeine and morphine?
10% of codeine is metabolised to morphine | Side-effect profile may be similar
68
What is the adult dose of codeine?
30-60mg hourly
69
Give 3 examples of strong opioids
Morphine Pethidine Fentanyl
70
How does morphine work?
Acts on M and K opioid receptors in brain and spinal cord | Reduce membrane excitability to nociceptive impulses
71
What are the side effects of morphine?
``` Respiratory depression Reduced response to hypoxia and hypercapnia Anti-tussive (stops coughing) Nausea, vomiting, constipation Urinary retention Drowsiness ```
72
What is the adults dose of morphine?
0.1-0.2 mg/kg
73
What is PCA?
Patient controlled analgesia Pump programmed to deliver a bolus dose of drug when the patient operates a hand set Dose is 1mg with a lock-out of 5 mins
74
Where is an epidural put?
``` Epidural space (potential space) Space in which nerves run to join the cord ```
75
Where is spinal analgesia inserted?
Into the CSF | Blocks fibres at the cord level
76
What is entonox?
Gaseous mixture of 50% O2 and 50% nitrous oxide
77
Why may hospital patients be malnourished?
``` Increased nutritional requirements Increased losses eg stoma Decreased intake eg dysphagia Treatment effects (nausea, diarrhoea) Enforced starvation Missing meals Difficulty feeding Unappetising food ```
78
What is the best form of nutrition?
Enteral - through GI tract
79
When should parenteral nutrition be considered?
If the patient will become malnourished without it | Eg small bowel Crohn's when food not being absorbed
80
How is TPN given?
Central venous line or PICC line
81
What are the potential complications of TPN?
Sepsis from central line insertion | Thrombosis in central vein may lead to PE
82
What are the 3 indications for IV fluids?
Maintenance Resuscitation of pre-existing deficit Replacement of ongoing losses
83
What proportion of bodily fluid is extracellular?
1/3
84
What proportion of body fluid is intravascular?
1/15
85
What is the minimum urine output that is considered adequate?
0.5ml/kg/hr
86
Why are even small changes in plasma potassium bad?
Potassium is mainly intracellular | There may be large changes before plasma levels change
87
Why do IV fluids need to be isotonic with plasma?
If hypotonic - red cell haemolysis | If hypertonic - red cell crenation
88
Name 3 crystalloid fluids
Normal saline Dextrose Hartmann's
89
Name 4 colloid solutions
Volpex Starch Albumin Blood products
90
What does 1 litre of 0.9% normal saline contain?
154mmol Na+ | 154mmol Cl-
91
What does 1 litre of Hartmann's contain?
131mmol Na+ 5mmol K+ 111mmol Cl-
92
What is the maximum safe rate to deliver IV potassium?
5mmol/hr
93
What proportion of 5% dextrose solution remains in plasma?
1/15 | Glucose taken up rapidly by cells, so solution acts just like water
94
What proportion of 0.9% saline remains in plasma?
1/5
95
What proportion of colloid solutions stays in plasma and why?
All of it Contains proteins, which can't cross the capillary membrane. Their osmotic effect means all the water remains in plasma too
96
What are the maintenance requirements of sodium for adults?
2mmol/kg/24h
97
What are the maintenance requirements of water for adults?
40ml/kg/24h
98
What are the potassium requirements for adults?
1 mmol/kg/24h
99
When may fluid replacement be required?
Vomiting Diarrhoea High output stoma Enterocutaneous fistula
100
What ions is diarrhoea rich in?
K+ and HCO3-
101
What ions is vomit rich in?
K+, H+ and Cl-
102
How do you assess a patient's fluid status?
``` Peripheral perfusion Pulse rate, blood pressure JVP Flow-based measurements Urine output ```

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